Ophthalmology and Optometry Coding Alert

When Medicare patients go to the ophthalmologist for a complete medical exam, they must be billed separately for the refraction part of the visit, under Medicare rules. Connie Selby, billing manager for Jay C. Grochmal, MD, and Dean S. Glaros, MD, of Baltimore, MD, wonder how to best bill Medicare patients for this fee without upsetting them? The biller uses 99215 for an established patient comprehensive exam, and 99204 for a new patient comprehensive exam. We cant justify having to charge the patient another $20 to $35 for a refraction, says Selby. But Medicare says we must do this or we can be fined.

Part of Selbys difficulty stems from the fact that she is using her fee schedule for the Evaluation and Management (E/M) services codes, and doesnt know whether to bundle the refraction code (92015) into these E/M codes or add it as a separate item. The answer is that she needs to add 92015 to the claim, separating it out of the E/M services code. This may require an adjustment to her fee schedule. We cant bill Medicare more than we charge other payers, notes Selby.

But the main concernbilling for refractions without upsetting patients with the feeshould not be a problem, our sources say. Medicare patients must understand that refractions are not covered by Medicarejust as they are not covered by commercial health plans without vision ridersand that the patient is responsible for them. We talked to two practices which collect this refraction fee up frontone has been doing it for years, and the other just started doing so. Both collect the refraction fee with relatively little difficulty.

We collect the 20-percent co-pay for the medical portion, and the $20 for the refraction, says Diane Miller, accounts receivable manager for Rochester Eye Associates, a three-ophthalmologist, one-optometrist practice in Rochester, NY. The practices Medicare patients know that refractions are a non-covered service, says Miller, so there isnt any problem.

Connie Erosenko, patient accounts manager for Laurel Eye Clinic, a two-ophthalmologist, six-optometrist practice in Brookville, PA, has just recently started charging patients for refractions. So far, weve had no complaints, says Erosenko, who also collects for the refractions at the time of service.

Optical Shops and Exam Pay-up

Both practices have optical shops, which may help in the collection of the refraction fee. It makes it convenient for getting the prescriptions filled, says Miller. It also helps the profitability of the practice.

On the other hand, as Erosenko notes, its also possible for patients to go to the lens room and not see anything they like. If we didnt charge for the refraction, then we would get nothing from this service, notes Erosenko. Her practice has 10 offices, and only four have lens rooms.

Millers practice has two satellite offices in addition to the main office. Only one of the satellites has an optical shop, but patients have started requesting that the practice add one at the other location as well.

Some patients do insist that you bill Medicare first for the refraction. Then, when the charge is denied, you can bill them. Both sources are resigned to this small number of unbending patients. If they insist we file it, then we do, explains Erosenko. But we make them sign a waiver first.

Educating Patient Can Help

Lise Roberts, vice president of Health Care Compliance Strategies, based in Syosset, NY, and a noted ophthalmology coding expert, recommends the following: Get a copy of the Medicare beneficiarys handbook from your local social security office and keep it at your front desk, she says. When the patient insists that Medicare will pay for the refraction and that you bill it, show them in the handbook where it specifically states that refractions are not a benefit of the Medicare program.

This often solves the problem right away, says Roberts, noting that a quick resolution prevents the costs associated with billing Medicare. If the patient says they have a secondary payer which does cover the refraction service if there is a Medicare denial, then you may want to bill it for the patient as a matter of good public relations, Roberts adds. Finally, many patients actually dont even know what the refraction service is. Make sure that whoever is performing the service communicates to the patient that they are now doing a refraction, Roberts urges. This is especially important now that Medicare is sending notices to beneficiaries asking them to advise Medicare when they believe the services billed were either not performed or were not medically necessary as they understand their conditions.

Tip: In some Medicare carrier jurisdictions, there may be times when you cannot collect from Medicare patients for refractionsfor example, within the 90-day post-op period for cataract surgery, says Erosenko. Check with your local carrier.